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The Case For Case Reports: Writing and Sharing Your Research
somatic research

By Diana Thompson

Originally published in Massage Bodywork magazine, January/February 2011. Copyright 2011. Associated Bodywork and Massage Professionals. All rights reserved.

In my first Somatic Research column ("Massage Therapy: The Invisible Profession," January/February 2010, page 114), I put out a call for action. I challenged us to influence research by attending research conferences and engaging in dialogue with the investigators.

I called on you to tell your clients' stories--to write case reports and get them published--so all could learn of our transformative and caring work. One year later, there is some evidence of progress, but we have a long way to go. While attendance more than doubled at the Highlighting Massage Therapy in CIM Research conference this year, as compared to 2005, the number of case reports submitted to the Massage Therapy Foundation (MTF) student and practitioner case report contests decreased. Only nine case reports were submitted to each contest, down from 21 in previous years. PubMed published 11 case reports on massage therapy in the past year--one written by a chiropractor, two by physical therapists, and two by traditional Chinese medicine practitioners.1 If research is to reflect the practices of massage and bodywork therapists, then we need to be contributing to the evidence base.

I am heeding the call to make case reporting easy and compelling, and encourage you once again to rise to the challenge, tell your stories, and inform our profession's body of knowledge.

I'll start by sharing why I am a proponent of case reports: I find this to be the perfect format for telling the powers that be (researchers, referring health-care providers, policy makers) who we are (complex and unconventional), what we do (more than just a back rub), why people choose us (we touch more than their physical pain), and how powerful intentional touch can be. It is a blessing not to be able to diagnose, leaving us free to see clients as human beings to partner with, whose stories lead us on a path toward wholeness, rather than only relating to the illness--something to name and conquer. Our stories will likely not focus on unusual conditions or describe novel treatment procedures, because our ordinary client approach is still unusual to many. Our job is to illuminate the reader of the totality of a massage or bodywork session.

What Is A Case Report?
Case reports consist of a detailed description of an individual client interaction, coupled with a literature review of research on similar subject matter. They tell of our day-to-day experiences and pose the questions we contemplate in our practices. The reports may focus on the norm-- describing a typical client, assessment tools, or technique application, or they may tell of an unusual outcome or unique approach to a condition or disease. A case report that is well observed and linked to published literature can be valuable even if there is nothing unique in the details.2

Case reports stimulate learning and research and they complement evidence-based medicine.3 Practitioners can learn from each other's successes and failures without being in close proximity; internships are sorely lacking in our profession, making sharing knowledge through case reports even more critical. Results of a single case report cannot establish cause and effect, but they can lead researchers to do the kinds of studies that might. Most importantly, case reports develop critical thinking and problem-solving skills that hone our aptitude as practitioners.

Case reports are considered anecdotal evidence, and as such, are less scientifically rigorous than controlled clinical trials involving a larger sample size. Proponents argue that case reports have scientific value due to their role in discovering new diseases and unexpected effects (adverse or beneficial), and educational value due to their descriptive nature. They are considered one of the cornerstones of medical progress and are encouraged in conventional medicine.4

New on the scene are interactive blogging sites, inviting health-care providers to submit their medical case reports and solve other cases.5 There are an increasing number of peer-reviewed journals that are encouraging the submission of case reports (British Medical Journal, Elsevier) or have launched journals dedicated to compiling case reports (The Journal of Medical Case Reports, The Case Report Journal, The International Case Reports Journal). The call for contributions to the evidence base from individuals in the field is on the rise, across conventional and alternative disciplines.

Writing A Case Report
First, identify what you are curious about. Do you have a client with a particular condition that you would like to learn more about or are effective in relieving? Or are you more interested in knowing if others do what you do? Is there one aspect of a client interaction that interests you, or do you wish to tell the whole story? Narrow down your interests and identify the style that best suits the story you wish to tell. There are three presentation styles for writing case reports: educational, assessment, and treatment or management.

Educational. These case reports illustrate common situations and are used to establish a baseline for practices. Individual aspects of a practice are described--intake procedures, assessment tools, treatment techniques, and homework assignments--for typical conditions so that atypical presentations have a comparison. This style is used to depict who we are, who our clients are, what we do, and how we do it. Outcomes are not the central focus of educational case reports. Basic information recounted with great detail is paramount and is used to build the foundation that defines our work.

Assessment. These case reports describe and discuss analytical methods used to evaluate a client with uncommon conditions. This assumes there are documented standards of care for common conditions. In the case of many massage and bodywork disciplines, standard assessment protocols are not entirely defined. This opens the door for us to individually define the assessment tools and techniques we use for particular conditions--common or uncommon--so we can begin to culminate standard practices. This style of case report invites us to go beyond simply identifying the tools and techniques we employ, and pushes us to describe our clinical decision-making process: why we picked that tool and how it influenced our treatment plan. A good example of this type of case report is "Clinical Reasoning in Massage Therapy," by Kim LeMoon,6 which spoke of a series of interview questions that helped her identify the source of her client's pain, changed her treatment approach, and finally provided the client relief.

Treatment or Management. These case reports are most common. A treatment-focused report follows a client through a session or series of sessions and describes everything from the client profile to the treatment outcomes. The client's condition is discussed, including a full literature search on the condition, symptoms, and common treatments. The treatment plan is identified and its implementation described in detail. Subjective and objective measurements from before and after the treatments are compared and outcomes are charted on graphs. Outcomes are the primary focus, detailing each step along the way. Several examples of this style can be found at www.massagetherapyfoundation.org/practitionercontest.html.

All three styles of case reports can be written from either a prospective or retrospective approach. Prospective reports are conducted in real time. A client is identified, one that presents a particular challenge or represents a common profile. A literature search on the presenting condition is conducted in advance of the treatment and influences the clinical decision-making (evidence-informed practice). Assessment protocols are predetermined, and results are carefully measured and tracked over time. The treatment plan is also predetermined but can be modified if documented based on the client's progress and preferences.

Retrospective reports are identified and compiled after the sessions have been completed. Perhaps after reading this article you are prompted to tell a client story from last year, one that taught you much about relieving chronic pain. It is acceptable to go back into your files to write up the sessions with Sophia, the feisty 75-year-old with osteoarthritis. This requires the consistent use of measurement tools and clear chart notes or progress reports that describe clinical reasoning and the methods of care provided.

Case Report Structure
When you are ready to begin writing, follow this outline:
- Title, Acknowledgements.
- Abstract.
- Introduction.
- Methods.
- Results.
- Discussion/Conclusion.
- References.

The title of a case report succinctly describes the study, including who, how, why, and what happened. In the title "Manual lymphatic drainage and movement reeducation therapy is used to delay knee replacement surgery in an active older adult female with osteoarthritis of the knee: A case report," the client (who) is described as an active older adult female. The intervention (how) is a combination of manual lymphatic drainage and movement reeducation therapy. The condition (why) is osteoarthritis of the knee. The outcome (what happened) is delaying knee replacement surgery.

I recommend writing the title early on. It is a great way to identify the parameters of the study and clarify your intent. If the title doesn't get you excited, pick another topic.

Acknowledgements are made on the title page of a case report. It is acceptable practice to involve others in conducting research, case reports included. You may enlist the help of a colleague, teacher, or mentor to assist you with your literature search, help you design the treatment plan, or edit your paper. Space is provided to thank those who contributed to the development of the project or the paper's revisions.

The abstract summarizes the study and must be organized using a standard format. Abstracts commonly include the purpose of the study, methods, results, conclusions, and keywords. The abstract follows the standard structure for the case report itself and simply retells the highlights of the study in an abbreviated format. This cannot be written until the paper is complete. Keywords are the only part of an abstract not found in the paper itself and are used to help with database searches. List words that will help people find your case report. In the example above, the words massage therapy are not in the title, so should be listed as keywords. Chronic pain is also not mentioned in the title, but it is a debilitating aspect of osteoarthritis and would be a helpful search term as well.

The introduction describes the purpose of the study, providing background information on the condition or technique, and states the hypothesis--why massage is reasonable and potentially beneficial for the client. In the example above, the introduction would include the signs and symptoms of osteoarthritis, demographic information on the prevalence of this condition in the older adult population, and a literature search of current research on the use of massage or similar modalities for this condition. The stated objective is to delay knee surgery, so research studies that demonstrate a reduction in the symptoms and the ability to maintain current activity levels as a result of the intervention will be effective in substantiating the hypothesis.

The methods section covers two broad topic areas: the profile of the client and the treatment plan. The profile of the client includes a detailed account of how the condition affects the client--presenting symptoms and changes in activities of daily living--and a medical history as it pertains to the condition. Also included are findings from other members of the client's health-care team, including the physician's diagnosis and recommendations for care. Most importantly, address the client's desired outcomes, not just your own.

The second part of the methods section--the treatment plan--details the selected massage and bodywork techniques and assessment techniques, how and where they are applied, the duration and frequency of sessions, and a rationale for the plan. The selections should be supported in the literature; if not, a rationale is expected.

The results section presents data in an organized fashion: charts, graphs, or tables, with captions and legends. Common assessments include range of motion, pain levels, or disability indices, and are collected periodically over time. For an example of pain levels charted over a period of several sessions, see the Pain Scale above. If any changes were made to the treatment plan once the course of care began, describe them in this section and provide the rationale.

Discussions/conclusions provide meaning to the results. Here, explain the effects of the treatment, how they support or refute the hypothesis, and suggested implications to the profession. Identify limitations to the study--what you learned that you might do differently next time or recommend that someone else consider in the future. For example, knee swelling may have been reduced as reported by the client, but no measurements were taken and therefore cannot be objectively accounted for. A recommendation can be made to include this assessment in future studies.

Most importantly, tell it like it is and avoid exaggerating outcomes or conclusions. Unfounded claims diminish the impact of the report. It is more respectable to identify your shortcomings and inform future research than to overstate your results. Be measured in your assertions, be open to alternative possibilities, and recognize your limitations.

Sharing Your Case Report
Now it's time to get it published. There are two journals that focus on massage and bodywork research: The International Journal of Therapeutic Massage and Bodywork (www.ijtmb.org) and The Journal of Bodywork and Movement Therapies (www.elsevier.com/jbmt). Both are peer-reviewed scientific journals with submission criteria outlined on the websites. Follow the guidelines and submit electronically.

A preliminary step is to submit your case report to the MTF Case Report Contest. Guidelines for writing case reports and for submission are on the website (www.massagetherapyfoundation.org/practitionercontest.html).
A committee of researchers and practitioners review the reports, and if you place in the top three, detailed feedback is provided and prizes are awarded. Support is available, should you choose to submit it for publication, and cash prizes follow if you are selected for publication.

Once your paper is submitted to a peer-reviewed journal, a rigorous review is employed. The paper is critiqued by two or more researchers or advanced practitioners. Comments are exhaustive and usually require an extensive rewrite. This process ensures the paper is fit for publication and will withstand critique by readers, including scientists, physicians, and the like. Support through the MTF contest can provide the fortification necessary to weather the critique.

Writing a case report is challenging enough. Getting it published can be downright intimidating. While it can be a humbling experience, it is most certainly an educational opportunity for all and well worth the effort. Those who persevere will be rewarded financially and professionally. Here's some encouragement from Glenda Keller, the 2009 MTF case report contest winner: "For me, doing a case study is a wonderful opportunity to further the massage therapy profession. I love being able to research a client's condition and expand on my knowledge. Most importantly, if the treatments are successful, it is very rewarding and satisfying to help the client. I encourage everyone to try it!"

A licensed massage practitioner since 1984, Diana Thompson has created a varied and interesting career out of massage: from specializing in pre- and postsurgical lymph drainage to teaching, writing, consulting, and volunteering. Her consulting includes assisting insurance carriers on integrating massage into insurance plans and educating researchers on massage therapy theory and practice to ensure research projects and protocols are designed to
match how we practice. Contact her at soapsage@comcast.net.


Notes
1. PubMed, accessed November 2010, www.ncbi.nlm.nih.gov/pubmed.

2. D. Jenkins, "What Shall We Do with Case Reports?"
British Medical Journal (November 2008).

3. Ibid.

4. J.P. Vandenbroucke, "In Defense of Case Reports and Case Series,"
Annals of Internal Medicine 134, no. 4 (2001): 330-4.

5. "Medical Case Reports, Report Your Case, Solve Other Cases," Interactive Medical Blogging, accessed November 2010, www.goomedic.com/medical-case-reports-report-your-case-solve-other-cases-interactive-medical-blogging.html.

6. K. LeMoon, "Clinical Reasoning in Massage Therapy,"
International Journal of Therapeutic Massage and Bodywork: Research, Education, and Practice 1, no. 1 (2001).




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- Levels of Evidence: How to Learn What We Want to Know
- Session Planning: Making Informed Decisions for Older Clients
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